Healthcare payment policy and regulation
Payment policy and regulation encompasses the various rules, guidelines and laws governing healthcare's financial aspects, including Medicare and Medicaid reimbursement rates, medical billing, and claims administration. Payment policy and regulation also plays a critical role in shaping the healthcare landscape, affecting service accessibility and affordability.
Top Stories
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04 Nov 2024
CMS highlights maternal care in CY 2025 OPPS, ASC final rule
The CMS CY 2025 OPPS, ASC final rule aims to reduce maternal mortality, remove barriers to care for formerly incarcerated individuals and enhance health equity. Continue Reading
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04 Nov 2024
CMS finalizes CY 2025 Medicare physician fee schedule rule
CMS issued the CY 2025 Medicare physician fee schedule final rule, which included updates to payment policies and average payment rate reductions. Continue Reading
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01 Jun 2020
OIG to Audit $50B in Coronavirus Relief Funds Given to Providers
The audit will determine whether HHS controls over coronavirus relief funds to hospitals and other providers were correctly calculated and disbursed. Continue Reading
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18 May 2020
Latest Coronavirus Relief Bill Seeks Another $100B for Providers
The HEROES Act would allocate another $100B to provider reimbursement, as well as increase the federal matching rate for Medicaid and seek COBRA subsidies. Continue Reading
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15 May 2020
Healthcare Organizations Unsure of Stimulus Relief Package Impact
Many healthcare stakeholders are unsure of the impacts the recent stimulus relief package will have on their organization, according to a recent Insights by Xtelligent Healthcare Media survey. Continue Reading
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13 May 2020
AHA Slams CMS for Advancing Hospital Price Transparency Rule
The AHA opposed CMS’ latest attempt to advance hospital price transparency by mandating facilities to publish privately negotiated rates and potentially using that data to set future Medicare reimbursement rates. Continue Reading
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11 May 2020
CMS Proposes to Increase Inpatient Medicare Reimbursement by 1.6%
The proposed rule would also create a new inpatient Medicare reimbursement category for CAR T-cell therapy and a new tech add-on payment for antimicrobial use. Continue Reading
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11 May 2020
Few States Have Robust Healthcare Price Transparency Laws
Only 6 states require healthcare price transparency from providers, carriers, or both, while 33 states have no laws around healthcare price transparency, a new report shows. Continue Reading
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05 May 2020
Hospitals Ask for Relief from Healthcare Fraud Laws During COVID-19
AHA and other hospital groups called on the Justice Department to stop imposing penalties on providers whose coronavirus-related remuneration violate healthcare fraud laws during crisis. Continue Reading
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01 May 2020
CMS Reveals More Flexibility with Medicare Payment, MSSP Changes
New flexibilities will enable hospitals to deliver a wider range of care during the COVID-19 crisis, including telehealth and value-based care, and still receive stable, predictable Medicare payment, CMS stated. Continue Reading
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23 Apr 2020
HHS Unveils Plan to Divvy Up Rest of $100B Provider Relief Fund
Hospitals in COVID-19 hotspots will get about $10B of the CARES Act provider relief fund, while the bulk will go to Medicare providers and the treatment of the uninsured. Continue Reading
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22 Apr 2020
Hospitals Slated to Get $75B from New Coronavirus Relief Bill
The coronavirus relief bill would also replenish the Paycheck Protection Program and provide $25B for COVID-19 testing. Continue Reading
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21 Apr 2020
CMS Issues Guidance on Resuming Elective Services in Certain Areas
The guidance updates CMS’ previous recommendation to halt all non-emergent, elective services to free up capacity and PPE for COVID-19 cases. Continue Reading
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16 Apr 2020
Senate Dems Want $100B Distributed Based on COVID-19 Hotspots
Senators Schumer, Murray, and Wyden criticized HHS’ method for distributing the first $30B in CARES Act funding for hospitals and called on the rest go to COVID-19 hotspots. Continue Reading
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15 Apr 2020
Medicare Payment Doubles for High-Production Coronavirus Lab Tests
CMS is boosting Medicare payment to $100 for coronavirus lab tests that can process more than 200 specimens a day effective April 14 through the duration of the national emergency. Continue Reading
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14 Apr 2020
CMS Unveils More Flexibilities to Maximize Healthcare Workforce
New healthcare workforce flexibilities will allow hospitals to quickly and virtually expand their staff and use them the most efficient way possible as COVID-19 cases surge, CMS stated. Continue Reading
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13 Apr 2020
2.3% Medicare Payment Hike Planned for Skilled Nursing Facilities
CMS is also proposing Medicare payment increases of over 2% for inpatient psychiatric facilities and hospices in its latest round of payment rules for FY 2021. Continue Reading
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13 Apr 2020
HHS Pays Out First Round of CARES Act Funding to Hospitals
HHS is distributing $30B of the $100B in CARES Act funding for healthcare providers using Medicare FFS revenue from 2019, the department announced. Continue Reading
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31 Mar 2020
CMS to Pay For Hospital COVID-19 Care Furnished in Other Settings
CMS also relaxed other regulations to boost hospital capacity and workforce, including using non-healthcare settings for COVID-19 care and paperwork requirements. Continue Reading
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26 Mar 2020
Congress Passes CARES Act Giving $100B in Hospital Funds for COVID-19
The $2T coronavirus stimulus package will provide hospital funding through increased Medicare payments and other grants. Continue Reading
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19 Mar 2020
Providers Ask Congress for Financial Assistance to Combat COVID-19
Payroll tax cuts, reimbursement for telemedicine, and relief from quality reporting are among the recommendations providers had for Congress during the COVID-19 outbreak. Continue Reading
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18 Mar 2020
AMA Unveils New CPT Code for Coronavirus Test
The CPT Editorial Panel approved a new CPT code that will support data-driven resource and allocation planning during the novel coronavirus outbreak. Continue Reading
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17 Mar 2020
Key Waivers, Regulatory Flexibility for Providers During COVID-19
President Trump declared COVID-19 a national emergency. Here are the key regulatory flexibilities the state of emergency will give providers to help them manage the outbreak and get paid for care. Continue Reading
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13 Mar 2020
Out-of-Network Payment Cap Would Cut Hospital Spending by $124B
Savings from capping out-of-network payment rates could save as much as $124 billion in hospital spending, making the policy a potential alternative to Medicare-for-All. Continue Reading
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09 Mar 2020
ACOs Back Hospitalization Alerts in Final Interoperability Rule
ACOs applaud CMS for finalizing a new Medicare requirement on hospitalization alerts in the new interoperability rule. But others are still unsure of the rule’s overall impact. Continue Reading
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06 Mar 2020
CMS Develops New Billing Codes for Coronavirus Lab Tests
Two HCPCS billing codes will allow clinical laboratories and other providers to bill for certain coronavirus lab tests and support testing and tracking of new cases. Continue Reading
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05 Mar 2020
Community Health Centers to Get Funding for Coronavirus Outbreak
The House $8.3B spending package for the coronavirus outbreak would allocate $100M to community health centers to support preparedness and response. Continue Reading
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02 Mar 2020
FDA Allows Coronavirus Diagnostic Testing in Certain Hospital Labs
The new FDA policy will expand novel coronavirus diagnostic testing to certain clinical laboratories, including those in hospitals. Continue Reading
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26 Feb 2020
More States Passing Laws to Preserve Provider Competition
An updated report shows that more states are implementing price transparency and other laws to protect provider competition in the face of rapid consolidation. Continue Reading
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24 Feb 2020
CMS Seeks Extension for Comprehensive Care for Joint Replacement
A rule proposed would extend the Comprehensive Care for Joint Replacement for another 3 years and make changes to the bundled payments for certain episodes, including new outpatient procedures. Continue Reading
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18 Feb 2020
Policymakers, Industry Leaders Call for Innovation Center Changes
The CMS Innovation Center has been key to accelerating care delivery and payment reform, but industry leaders are now seeking changes to the center leading change. Continue Reading
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11 Feb 2020
Trump Budget Eyes More Site-Neutral, Hospital Reimbursement Cuts
President Trump’s proposed FY 2021 budget includes hospital reimbursement cuts, including more site-neutral payments, as well as a unified post-acute care payment system. Continue Reading
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06 Feb 2020
HHS Defends Hospital Price Transparency Rule to Judge
HHS motioned for the court to throw out a lawsuit challenging a hospital price transparency rule, arguing that Congress intended for prices to be public. Continue Reading
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27 Jan 2020
One-Third of Providers Believe Payer Audits Are a Burden
Most providers report negative encounters with payer audits because of high administrative costs and abrasive experiences due to high volume of medical requests. Continue Reading
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20 Jan 2020
DoJ Recovered $2.6B from Healthcare Fraud Cases in 2019
Of the more $3 billion in settlements and judgments recovered by the department in 2019, $2.6 billion stemmed from healthcare fraud cases. Continue Reading
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16 Jan 2020
Cost Disparities Spell Trouble for Healthcare Price Transparency
Crowe found a 297% difference between the lowest and highest gross charge in individual hospital procedures, showing potential issues in the healthcare price transparency order. Continue Reading
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15 Jan 2020
GAO Calls for More Oversight of 340B Drug Pricing Program
Processes for determining nongovernmental hospital eligibility for the 340B Drug Pricing Program fail to identify hospitals without valid contracts, GAO reports. Continue Reading
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15 Jan 2020
AHA, AAMC Sue HHS Again Over Outpatient Site-Neutral Payments
The associations along with several member hospitals are looking to block outpatient site-neutral payments in 2020 following their successful lawsuit last year. Continue Reading
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14 Jan 2020
1 in 3 Rural Adults Report Issues Affording Medical Bills
32% of rural adults reported problems paying dental and medical bills, including 19% saying they have major affordability problems, a JAMA study reveals. Continue Reading
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09 Jan 2020
US Administrative Healthcare Spending Reached $812B in 2017
Administrative expenditures represented about one-third of total healthcare spending in the US, twice the amount in Canada, a new study finds. Continue Reading
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09 Jan 2020
Childbirth Complications Boost Hospital Costs by 20%
Complications including SMM, behavioral health disorders, diabetes, and chronic pain raise hospital costs by 20% and increase mothers’ hospital stay by 70-75%. Continue Reading
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07 Jan 2020
Beaumont Health Signs $6.1B Hospital Merger Deal with Summa Health
The hospital merger agreement will allow both organizations to boost capital and drive growth as well as enhance quality of care for individuals and communities. Continue Reading
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07 Jan 2020
Former Anthem Exec to Lead CMMI, Value-Based Care Efforts at HHS
Brad Smith, the former COO of Anthem’s Diversified Business Group, will serve as director of CMMI and senior advisor to Secretary Azar for value-based care. Continue Reading
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06 Jan 2020
AMA Offers Checklist for E/M Coding and Documentation Changes
The checklist gives physician practice tips on how to manage E/M coding and documentation changes in order to maximize burden relief. Continue Reading
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03 Jan 2020
Medical Groups Worry About Risk in Anti-Kickback, Stark Law Reform
Policy alignment, financial risk threshold modification, and overall flexibility will help tackle concerns surrounding proposed Anti-Kickback Statute and Stark Law reform, medical groups say. Continue Reading
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02 Jan 2020
PhrMA: 340B Hospitals Reimbursed 3X the Amount Paid for Drugs
The pharmaceutical industry group reported that, on average, 340B hospitals paid $1,591 per claim and received $4,673 in reimbursement. Continue Reading
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15 Nov 2019
New Healthcare Price Transparency Rule to Unveil Negotiated Rates
A final healthcare price transparency rule from HHS will require hospitals to post payer-specific negotiated rates and other charges by 2021. Continue Reading
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18 Jun 2019
MedPAC Suggests Elimination of Incident To Billing for APRNs, PAs
In addition to concerns about incident to billing, the commission also advised CMS to use a stay-based design for a unified post-acute care payment system and establish national ED coding guidelines. Continue Reading
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26 Jul 2018
Verma: Healthcare Payment Reform to Focus on Docs, Not Hospitals
Site-neutral payments, capitated reimbursement, and competitive bidding were among the provider-focused healthcare payment reforms suggested by CMS leader Seema Verma. Continue Reading
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05 Sep 2017
CMS Offers Value-Based Purchasing Exceptions After Hurricane Harvey
Providers in 32 Texas counties and five Louisiana parishes will be exempt from value-based purchasing and quality reporting requirements because of Hurricane Harvey. Continue Reading
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11 Aug 2015
ICD-1 to ICD-11 Timeline Highlights Healthcare’s Evolution
From ICD-9’s inception via The World Health Organization over 35 years ago to ICD-10’s kick-off this upcoming October, how far has the healthcare industry come? Continue Reading
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20 Feb 2015
Why Recent Attempts at Healthcare Reform Regulation Matter
Value-based care is buzzing among healthcare organizations. With new federal healthcare reform in effect, value-based care takes on new form in HHS news. Continue Reading
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09 Dec 2014
HIPAA Compliance within Revenue Cycle Management
The inclusion of HIPAA transactions intends to reduce administrative costs, but to do so, medical practices must strengthen their revenue cycle management. Continue Reading